Insight in how ICU's are run in the USA/Canada

I'm wondering. As I don't practice in the USA/Canada I have little experience with the way things are run on the other side of the ocean. So I was hoping if people could explain the structure somewhat. It's just for my own curiosity. In return I'll write a bit on how we (dis)organize things in Belgium.

Nurse specializationTo work in the ICU in Belgium you need to have your bachelor in nursing followed by something called a bachelor-after-bachelor in ICU and emergency care. This Ba-after-Ba is something you can either do directly following your bachelor in nursing or as part of an on-the-job training program. This is generally enough to get you anywhere in an ICU.

Belgium is a very rigid country when it comes to giving nurses any kind of "legal" right to participate in things beyond the scope of pure nursing. After years and years of battle a nurse is finally allowed to administer oxygen without a doctor's order and start an IV with normal saline when we feel the patient needs it.

Specializations like advanced nursing practice or any type of specialization in a part of the ICU-care is non existent. We don't have respiratory therapists, ANP's, PA's, circulation practitioners or anything.

We have a master's degree in nursing but that is a master in science and it is generally coupled to being a department head.

Level of ICU careBelgium has no formal level in ICU care. Which means that some hospitals think they "can do it all". It leads to skewed situations where for example children are not taken care of in a PICU but in a general ICU of a small hospital where they'll have 2 - 4 children per year. Or adults are being taken care of that are too ill for the relatively small hospital they are in and are transferred once "the damage is done".

I myself work in a university hospital. It has all the major specialties except pediatric cardiovascular surgery and pediatric/neonatal extra-corporeal support. Children requiring that type of care get transferred to another university hospital.

Our ICU complex consists of 71 "beds" and I think they are planning on increasing it to a capacity of 90 beds in the upcoming years. Of these 71 beds we have 30 beds for our NICU where every therapy is possible except (extensive) CV-surgery/ECMO. We have a 9 bed PICU but they'll also take in adults when there is a lack of children. The remaining beds are for the adults split up in a CVICU, SICU, MICU, PICU/NSICU and my department the garbage can but they'll politely call it polyvalent ICU. We originally started out as a combined PICU/CVICU/CCU but over the years a lot of things changed for the worst.

Our team consists only of nurses and one physician, a specialized intensivist. Assistants are floated to all the ICU's but are generally made up out of residents in internal medicine, anesthesiology and fellows doing their ICU.

HospitalOur hospital is a tertiary care facility consisting of 600+ beds. They have an extensive transplantation service. Generally the hospital is acknowledged for their cutting edge radiology, cath lab, intervention radiology, CV-surgery, ophthalmics and maternity.

We are a level I trauma center, but less then 2 km away there is another 800 bed hospital that is also a level I trauma center and they see a bit more trauma then we do. And there is also a 600+ bed hospital another 1 km away that is a level II trauma center. Whoever thought of building three hospitals so close to each other... Belgian logic I guess.

StaffingOut little unit consists of 7 beds and sometimes they'll desperately try to stuff 8 or 9 there if we would allow them to. But no can do anymore, if they want more space they'll have to build more beds.

During the day shift there are 4 nurses adding our n/p-ratio to 1:1,5 to 1:2. We can't really complain about the workload during those days if things stay calm. There is also this mad intensivist running around.
Evenings are run with three nurses. The intensivists goes home at 6/7 pm and we fall back to our on call staffing. This means there is one intensivist on call (@ his home). For the remainder we have two residents in anesthesiology running around and one resident in internal medicine.
Night shifts are run with two nurses. There is still the same intensivist on call from his home. And there is a resident in anesthesiology that we have to share with the cardiovascular medium care and sometimes the ER, but generally he/she is around somewhere in the ICU. The resident in internal medicine is around somewhere too but he is also on call for the ER, internal codes and everything internally medicine related that the ambulance gets called to. (fyi in Belgium we have nurses and doctors from the hospital in a specialized ambulance that go out to the homes of people). In practice this means that during the nights when you have a serious issue you just generally call the anesthesiology resident for a fast response.
The NICU has their own system I have no clue how they handle it.

Night shifts can be really busy. Since we are stretched to a 1:3 or 1:4 ratio whenever someone crashes/codes/gets admitted one nurse has to completely focus on that patient so he/she/it can receive 1:1 for the acute moment. But this means the other nurse goes to a 1:6 ratio. This sometimes happens for the remainder of the night shift.

Generally we work very autonomous in our ICUs especially during evenings and nights. We have a good understanding with our intensivist about what meds me can and cannot push without asking permission and which meds we can start continuously. We are allowed/required to make changes to vents, CVVHs, meds, IABPs. Only when we run into an issue we really can't solve we call the resident that is assigned to the ICU. Generally he is safeguarding the CVICU, because their intensivist is a little napoleon and they are all scared of him.
Our patients transported from other hospitals to our ICU are accompanied by our intensivists or the residents assigned to the ICU and a nurse from the ER. If we have to transport our patient somewhere in the hospital that is done by the ICU nurse and sometimes the resident depending on the acuity.

We barely have support staff. All we have are three women called nursing helps in a rough translation. But they only work during the day up to 3 pm they'll get our beds from the wards, get blood, run labs and get meds from the pharmacy. After 3 pm that becomes our job as well. Other than that we have a person called "head of the night" and basically we can ask him/her to get things for us urgently but only if we can't manage to go ourselves. Thankfully our lovely ER nurses know life at night in the ICU can be real hell at times and they'll go collect blood and meds for us when we really don't know what to do first.

General thoughts
Reading the above it sounds a lot worse than it is. In general we are happy to work where we work and not in the wards where during the night the n/p-ratio is 1:32 and during the day it can be somewhere from 1:10 - 1:15. I always feel bad when we have to push our patients on them.
Our patients seem satisfied and we try to give them the extra attention they need/want whenever we find the time. However I'm very grateful we generally are allowed to sedate our patients heavily in times of stress it keeps them happy and not complaining and us as well. And when we give them something called paracetamol "plus" they'll sleep really well not noticing all the alarms and not bother us for bowel movements in the middle of the night etc.

So I'm really wondering how the care is organized in other countries/other hospitals. In general the situation in my hospital is comparable to the national average.
I remember when an inspection came from the Netherlands to inspect our ICU's to see where our level of care was at. They were amazed we could pull of this level of care and satisfaction being as thin staffed as we were.

hi there! interesting information about ICU nursing in Belgium. I am originally from Brussels, but studied nursing in the States. I never worked as a nurse in Belgium. I have been an ICU nurse for a couple of years at a level 1 trauma and now work at a different hospital in their mixed med/surg/ccu ICU. The nurse/patient ratio is mostly 1:2 and any patient with a mechanical heart device and early post-op (heart, liver etc) is 1:1. CRRT and IABP are also 1:1. Intensivist run the unit. There are some residents, but everything is mostly run through the intensivist. As far as interdisciplinary work, we have respiratory therapy, physical therapy etc. We do have aides, really...they mostly stock the rooms with supplied...When I worked at the level 1 trauma center, the aides were great helpers with turning patients, bathing, and getting blood sugar checks. Thanks for sharing that info!